Provider Resource Center

Serving the OneCare network of health care professionals and clinicians

Monthly E-Newsletter: Need-to-Know from Your ACO

At the beginning of each month OneCare sends an email to our network with important need-to-know information and links necessary to be successful in the OneCare accountable care organization, supporting health care delivery reform across the continuum of care.

Recent newsletters:

Quality Measures

2025 Annual Quality Measures

2025 Quality Measure Medicare Medicaid Self-Funded MVP QHP PHM Measure
Follow-Up after Discharge from the ED for Mental Health or Alcohol or Other Drug Dependence (30-Day) (NQF#2605) Yes
Follow-Up after ED Visit for Substance Use – 30-Day (HEDIS FUA) Yes Yes Yes
Follow-Up after ED Visit for Mental Illness -30 Day (HEDIS FUM) Yes Yes Yes
Hospital-Wide, 30 Day, All Cause Unplanned Readmission (Quality ID#479) Yes
Clinician and Clinican Group Risk-Standardized Acute-Admission Rate for Patients with Multiple Chronic Conditions (Quality ID#484) Yes
Risk Standardized, Hospital Admission Rate for Patients with Multiple Chronic Conditions (18 and over) Yes
Child and Adolescent Well-Care Visits 3-21 (HEDIS WCV) Yes Yes Yes Yes
Developmental Screening in the First Three Years of Life (CMS Child Core C-DEV) Yes Yes Yes
ACO All-Cause Readmissions (HEDIS PCR) Yes
Initiation of Substance Use Disorder Treatment (Quality ID# 305-Medicare)

Initiation of Substance Use Disorder Treatment (HEDIS IET- Medicaid, MVP, PHM)

Yes Yes Yes Yes
Engagement of Substance Use Disorder Treatment (Quality ID# 305-Medicare)

Engagement of Substance Use Disorder Treatment (HEDIS IET-Medicaid, MVP, PHM)

Yes Yes Yes Yes
Follow Up after ED Visits for Patients with Mulitiple Chronic Conditions (HEDIS FMC) Yes Yes
Follow-Up After Hospitalization for Mental Illness (7 Days) (HEDIS FUH) Yes Yes Yes
Breast Cancer Screening (HEDIS BCS-E) Yes
Cervical Cancer Screening (HEDIS CCS-E) Yes
Medicare Annual Wellness Visit Yes
Influenza Immunization (Quality ID# 110) Yes
Colorectal Cancer Screening (Quality ID# 113, HEDIS COL-E) Yes Yes Yes
Tobacco Use Assessment and Cessation Intervention (Quality ID# 226) Yes Yes
Screening for Clinical Depression and Follow-Up Plan (Quality ID# 134) Yes Yes
Diabetes Hemoglobin (HbA1c) Poor Control (>9.0%) (Quality ID#001) Yes
Glycemic Status Assessment for Patients with Diabetes (HEDIS GSD) Yes Yes Yes
Hypertension: Controlling High Blood Pressure (Quality ID# 236, HEDIS CBP) Yes Yes Yes Yes Yes
CAHPS Patient Experience Yes Yes Yes

To find information on each of these 2025 annual quality measures, please visit the OneCare secure portal. There you will find measure specification booklets that contain individual “provider tip sheets” for each payer program that outline important information for all claims and clinical quality measures. These helpful tools can be found on the portal under category: 2025 Annual Quality Measures category.

2025 Population Health Model Measures

2025 Population Health Model Measure Measure Description 2025 Target Rate Percentile Benchmark
Child and Adolescent Well-Care Visits 3-21 (HEDIS WCV) The percentage of members 3-21 years of age who had at least one comprehensive well care visit with a PCP or an OB/GYN practitioner during the measurement year. 64.74 % Medicaid 90th
(3-21)
Developmental Screening in the First Three Years of Life (CMS Child Core C-DEV) The percentage of children screened for risk of developmental, behavioral, and social delays using a standardized screening tool in the 12 months preceding, or on their first, second, or third birthday. 51.60% Medicaid Child Core Set 75th
Medicare Annual Wellness Visit A yearly check-up for Medicare enrollees assisting participants the opportunity to gain information about their patients, including medical and family history, health risks, and specific vitals. A proactive approach to encourage patients to be proactive about their health and engage in preventive health services. 51.80% National ALL ACO Benchmarking - 50th
Hypertension: Controlling High Blood Pressure (Quality ID# 236, HEDIS CBP) The percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure (BP) was adequately controlled (<140/90 mmHg) during the measurement. 69.37 % Medicaid 75th
Initiation of Substance Use Disorder Treatment (HEDIS IET) The percentage of new substance use disorder (SUD) episodes that result in treatment initiation and engagement. Two rates are reported: Initiation of SUD treatment (within 14 days) and Engagement of SUD treatment (within 34 days of initiation). 44.51% Medicaid 50th
Engagement of Substance Use Disorder Treatment (HEDIS IET) The percentage of new substance use disorder (SUD) episodes that result in treatment initiation and engagement. Two rates are reported: Initiation of SUD treatment (within 14 days) and Engagement of SUD treatment (within 34 days of initiation). 19.01% Medicaid 75th
Follow Up after ED Visits for Patients with Multiple Chronic Conditions (HEDIS FMC) The percentage of emergency department (ED) visits for members ages 18 and older who have multiple high-risk chronic conditions who had a follow up service within 7 days of ED visit. 56.50 % NCQA National Average Medicare PPO
Follow-Up after ED Visit for Substance Use - 30-Day (HEDIS FUA) The percentage of emergency department visits for members 13 years and older with a principal diagnosis of substance use disorder, or any diagnosis of drug overdose, for which there was a follow-up. 49.40% Medicaid 75th
Follow-Up after ED Visit for Mental Illness -30 Day (HEDIS FUM) The percentage of emergency department visits for members 6 years and older with a principal diagnosis of mental illness or intentional self-harm, who had a follow-up visit for mental illness. 73.12% Medicaid 90th
Follow-Up After Hospitalization for Mental Illness (7 Days) (HEDIS FUH) The percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness or intentional self-harm diagnosis and who had a follow-up visit with a mental health provider. 46.99% Medicaid 75th

To find information on each of the 2025 Population Health Model measures, please visit the OneCare secure portal where you will find the “PY2025 Provider Tip Sheets” that outline important information for all claims and clinical quality measures. They can be found under category: 2025.

Self-Reporting Dates and Deadlines

To qualify for the Population Health Model (PHM) payments and bonus payments, attributing primary care providers must complete mandatory online attestations and self-reporting in four areas: Hypertension control, Mental Health Screening, Social Determinants of Health Screening and Care Coordination activities.

For each data collection report, OneCare will send this initial email request two weeks before the due date, and a reminder email one week before.

Self-Reporting for Hypertension: Controlling High Blood Pressure (Quarterly)

Frequency of Reporting Email Request* Reporting Period Reporting Deadline
Quarter 1 March 3, 2025 March 1, 2024 –
February 28, 2025
March 14, 2025
Quarter 2 June 2, 2025 June 1, 2024 –
May 31, 2025
June 13, 2025
Quarter 3 September 1, 2025 September 1, 2024 –
August 31, 2025
September 12, 2025
Quarter 4 January 5, 2026 January 1, 2025 –
December 31, 2025
January 16, 2026

Email request* = This is the date you can expect to receive an email from OneCare with a link to a specific reporting form for your practice to submit data

Self-Reporting for Mental Health Screening Initiative (Biannually):

Frequency of Reporting Email Request* Reporting Period Reporting Deadline
Mid-year June 2, 2025 January 1, 2025 –
May 31, 2025
June 13, 2025
End-of-year January 5, 2026 January 1, 2025 –
December 31, 2025
January 16, 2026

Email request* = This is the date you can expect to receive an email from OneCare with a link to a specific reporting form for your practice to submit data

Self-Reporting for Health-Related Social Needs (Biannually):

Frequency of Reporting Email Request* Reporting Period Reporting Deadline
Mid-year June 2, 2025 January 1, 2025 –
May 31, 2025
June 13, 2025
End-of-year January 5, 2026 January 1, 2025 –
December 31, 2025
January 16, 2026

Email request* = This is the date you can expect to receive an email from OneCare with a link to a specific reporting form for your practice to submit data

Self-Reporting for Care Coordination (Triannually):

Frequency of Reporting Email Request* Reporting Period Reporting Deadline
Triannual 1 April 4, 2025 January 1, 2025 – March 31, 2025 April 18, 2025
Triannual 2 August 8, 2025 April 1, 2025 – July 31, 2025 August 22, 2025
Triannual 3 January 19, 2026 August 1, 2025 – December 31, 2025 January 23, 2026

Email request* = This is the date you can expect to receive an email from OneCare with a link to a specific reporting form for your practice to submit data

OneCare Care Coordination Program Resources

OneCare’s care coordination model supports a strong relationship between the patient, their primary care provider, and other members of a person’s care team. 

Strong performance in care coordination by our OneCare network is possible by:

  • Employment of evidence-based patient centered care coordination including designation of a lead care coordinator, shared care planning, and care team conferences.
  • Improvement in care managed rates for individuals by regularly reviewing patient panels, including those with complex needs experiencing avoidable healthcare utilization, for timely outreach and engagement in care coordination.
  • Complete, accurate, and timely tri-annual care coordination reporting of care managed attributed lives and associated data.
  • Timely response to care coordination validation audits demonstrating supportive evidence of data submitted with tri-annual reports.
  • Ongoing care coordinator professional development through attendance at OneCare education sessions and/or other evidence-based care coordination offerings.

 

Arcadia Impact Program

We know that individuals with multiple chronic conditions, limited functional status and/or psychosocial challenges are vulnerable and more likely to experience adverse events and poor health outcomes. We also know that individuals who are at risk for increasing or worsening health conditions such as multiple chronic conditions, limited function status and/or psychosocial challenges are vulnerable and often benefited by enrollment in a care management program.

The Arcadia Impact Program utilizes a sophisticated risk stratification tool available in OneCare Vermont’s data analytics platform, Arcadia, to provide visibility at the patient level into the degree of impact a care management intervention is likely to have on important health outcomes. These outcomes  include: emergent inpatient admissions, total cost of care, and preventable emergency department visits for the individual.

Arcadia combines multiple factors, including Emergency Department utilization, healthcare costs, and unplanned admissions coupled with social and economic factors influencing health to create the Arcadia Impact Program designation for each patient including:

 

  • Demographics, such as age and sex
  • Morbidity, as reflected by concurrent risk
  • Utilization, as reflected by outpatient and inpatient events (from claims data)
  • Disease State, as reflected by types of conditions
  • Socioeconomic Status, as reflected by census data on local conditions
  • Care Coordination, as reflected by provider mix (from claims data)
  • Health Condition, as reflected by labs, screenings, and observations

The resulting Arcadia Impact Program designations below are visible in the system at the individual patient level to inform care management program resource planning, as well as effective outreach and engagement of individuals in a population:

 

  • Very Strong Potential
  • Strong Potential
  • Good Potential
  • Some Potential
  • Not Recommended

    Access to the Arcadia data analytics platform can be requested by emailing data@onecarevt.org.

     

    Tri-Annual Care Coordination Reporting Details:

    This reporting template ensures the care coordination data is completed in a uniform manner. This completed template is to be uploaded to the OneCare portal by participating organizations three times per year.

     

    Organizations may use a report generated by an electronic medical record or the Excel spreadsheet provided, as long as the format and data are exactly as specified in the reporting guidelines.

    Please note that the template is formatted to include specific responses and orders of date. This cannot be changed or the data will not be accepted.

    Each organization is required to submit the tri-annual reporting template. Periodically, a narrative report may also be requested with the tri-annual reporting template.

     

    Annual Validation Audit Guidelines:

    Every organization will be audited at least once per year. The audits seek additional information that supports and validates self-reported care management data.

    Audit Process:

    • Network organizations participating in the Population Health Model submit triannual care coordination reporting inclusive of a list of care managed attributed lives and interventions.
    • Organizations are notified of audit and validation template is provided.
    • Selected organizations are audited on 10 individuals or the maximum number available.
    • Target areas of validation audit per care managed individual:
      • Evidence of lead care coordinator
      • Evidence of shared care plan
      • Evidence of cross organizational collaboration if so reported
      • Evidence of encounter frequency
      • Evidence of a care team conference if so reported
    • Organizations have four weeks to complete and submit documentation requested.
    • Organizations are responsible for providing adequate evidence in 90% or more of targeted areas.
    • If an organization is not able to provide 90% of adequate evidence, they will be subject to additional action based on the percentage of evidence provided.
    • If the organization is not responsive or does not demonstrate improvement, PHM payments may be affected.

    Care Coordination Program Definitions and Reference Guide

    Find at-a-glance program definitions and care coordination expectations and requirements:

     

    Care Coordination Toolkit:

    Find tools and resources for implementing and providing ongoing care coordination in your practice:

     

    Data Performance Reports Release Dates

    Each quarter, OneCare posts data performance reports to our secure portal.

    OneCare network providers will receive notification in the monthly Need-to-Know from Your ACO e-newsletter that the reports are coming soon and/or available on the portal, as well as through direct notification in one-on-one meetings and communications with your contacts on our team.

    *Dates subject to change – dates will be updated below and announced in our monthly Need-to-Know.

    Name of Report Frequency Release Date
    Primary Care Data and Analytics Report Quarterly January 15, 2025,
    April 15, 2025,
    July 15, 2025,
    October 15, 2025
    Health Service Area Data and Analytics Report Quarterly January 15, 2025,
    April 15, 2025,
    July 15, 2025,
    October 15, 2025
    Executive Summary Data and Analytics Report Quarterly January 15, 2025,
    April 15, 2025,
    July 15, 2025,
    October 15, 2025
    Care Coordination Summary Report Tri-annually March 14, 2025
    June 13, 2025
    November 14, 2025
    Care Coordination Attributed Members Report Tri-annually March 14, 2025
    June 13, 2025
    November 14, 2025
    Care Coordination Detailed Activity Report Tri-annually March 14, 2025
    June 13, 2025
    November 14, 2025
    Mental Health Screening Rates by Practice Mid-Year and End-of-Year July 15, 2025,
    January 23, 2026

    Webinars, Trainings, and Consultations

    To support our OneCare network in having the information, tools, and resources to be successful in the OneCare accountable care organization and transform the way health care is paid for and delivered, we host a series of webinars, trainings, and consultations appropriate for various segments of our network.

    You will be emailed either calendar appointments or invitations to register, depending on the offering. 

    *Dates subject to change – dates will be updated below and announced in our monthly Need-to-Know.

    Webinars and Trainings Frequency Registration or Recording Link Upcoming Dates
    Care Coordination Core Team Meeting Quarterly By Outlook invitation September 11, 2024
    12:00-12:45 pm
    Value-Based Care Webinar: Initiation and Engagement of Substance Use Disorder Network Spotlight As-needed View recording here July 2, 2024
    12:00-1:00 pm
    Social Determinants of Health/Health Related Social Needs Screening Network Spotlight Webinar As-needed View recording here Tuesday, September 24, 2024 from 12:00 – 1:00 pm
    PY2023 Annual Quality Measure Results Overview Annually View recording here Tuesday, October 29, 2024 from 12:00 – 12:50 pm
    2025 PHM Education Sessions Annually By Outlook invitation Wednesday, November 20, 2024 from 12:00 – 1:00 pm AND Tuesday, December 3, 2024 from 4:30 – 5:30 pm
    2025 Events To be announced To be announced To be announced

    Payments

    (Updated for 2025)

    Population Health Model

    Primary Care Payments

    • Fixed monthly base payment of $4.00 per member, per month (PMPM)
    • Bonus payment amount of $5.25 PMPM divided equally across all applicable measures
    • Monthly base payments are made to all providers from January through December 2025
    • All providers have the opportunity to earn their full bonus potential based on PHM measure performance for the entire 2025 performance year
    • Interim monthly PHM bonus payments begin in July 2025
    • Year-end reconciliation of PHM measure performance and bonus payments in approximately April 2026 (based on performance from 1/1/2025 – 12/31/2025)
    • PHM measures are applicable to all practices with one or more patients in the denominator
      • Example: if a practice achieves 4 targets out of 7 applicable measures, PHM bonus rate would be $5.25/7 = $0 .75 x 4 = $3.00 PMPM, if a practice achieves 4 targets out of 4 applicable measures $5.25/4 = $1.31 x 4 = $5.25 PMPM 

    1 – Contingent upon satisfying Eligible Participant Obligations (see PHM Policy)
    2 – Italicized date ranges are projected ranges for claims-based measures only, subject to data availability
    3 – Performance-based (not guaranteed); performance and monthly bonus payment amount updated quarterly in July and October
    4 – Full PHM bonus potential available ($3.15 PMPM X 12 mos. for PY24; $5.25 PMPM X 12 mos. for PY25)

    Payments for Designated Agencies

    • Monthly PMPM base payments based on each DA’s share of the total value of claims for care provided by DA’s to attributed lives under current ACO programs
    • Bonus payments for meeting or exceeding FMC target in the PHM
    • Additional $500k in PHM bonus funding for performance in DA specific measures (FUA, FUM, FUH)

    Payment for Home Health and Hospice

    • Monthly PMPM base payments based on agencies share of total value of claims for care provided by HHH agencies to attributed lives under current ACO programs
    • Bonus payments for meeting or exceeding FMC target in the PHM

    Payment for Area Agencies on Aging

    • Monthly PMPM payments based on each AAA’s relative share of assigned attributed lives in the AAA’s health service area

    • No bonus amount in 2025, money has been reallocated to “base” payments

    Eligible Participant, Preferred Provider, and Collaborator Obligations:

    • Participation in PHM and acceptance of PHM payments by Eligible Participants, Preferred Providers, and certain Collaborators constitutes an express agreement to align goals and priorities with the stated goals and priorities of OneCare, which includes, at minimum, working with OneCare to meet or exceed cost and quality targets under ACO Programs.
    • All Eligible Participants shall provide a medical home for Assigned Attributed Lives, as defined in 18 V.S.A. § 704, as an indication the Participant is committed to managing their patient population with high-quality, cost-effective, team-based care.
    • Eligible Participants, Preferred Providers, and Collaborators must actively participate in and report on care coordination activities, per the requirements set forth in policy and as outlined below, to receive any PHM payments under this policy. The guidance provided on the Provider Resource Center is overseen by OneCare’s Population Health Strategy Committee and will be updated with 2025 guidance on the OneCare website and promoted to participating members or upon request no later than November 1, 2024.

    Provider Accountabilities

    (Updated for 2025)

    Accountabilities Related to Health Care Transformation and Innovation:

    Promote strong performance in health care delivery in furtherance of achieving OneCare’s programmatic and strategic goals; embrace and demonstrate innovation in OneCare’s Population Health Model; integrate the “care model” (prevention, care coordination and care management), quality improvement, and health equity.

    Provider Accountability: Health Equity

    Health Related Social Needs/Social Determinants of Health Screening

    • Incorporate SDOH screening into yearly patient visits using the CMS Health-Related Social Needs Screening Tool and electronic data entry in an EHR.
    • Make SDOH screening results essential to holistic patient care.
    • Electronically report SDOH screening rates to OneCare using the CMS tool (questions 1-15).

    Mental Health Screening

    • Participants must administer mental health screening annually for depression and suicide risk for patients twelve years of age and older
    • A mental health follow-up plan for patients that screen positive must be documented
    • Participants must self-report mental health screening rates to OneCare twice annually via electronic submission

    Provider Accountability: Care Model and Quality

    OneCare will provide performance reporting and improvement programs

    • Actively pursue meeting targets in 75%+ of Population Health Model quality metrics for which the practice qualifies

    Provider Accountability: Total Cost of Care Improvement

    • Meet or exceed OneCare’s target for follow-up after emergency department visits for high-risk patients with multiple chronic conditions (HEDIS FMC)

    Accountabilities Related to Culture:

    Promote an engaged and aligned network to achieve OneCare’s goals.

    Provider Accountability: Good OneCare Citizenship

    Commit to OneCare’s values and act in alignment with them.

    Provider Accountability: Engagement

    Participate in at least 50% of OneCare value-based care meetings annually:

    • HSA Executive Consultations
    • PHM Performance Review
    • Care Coordination Meetings

    Provider Accountability: Technology

    By 1/1/25, use an Electronic Health Record compatible with CMS 2015 CEHRT standards and pursue advanced interoperability for data exchange with OneCare.

    Regional Clinical Representatives

    In 2024, OneCare brought back a previous initiative and hired 10 regional clinical representatives (RCRs) from across Vermont’s health service areas. RCR goals are to:

    • Champion for performance improvement in PHM measures
    • Use data to identify practice needs for a performance improvement plan
    • Support practice through partnership with a OneCare team member to identify opportunities for improvement
    • Track and review performance improvement plans relative to PHM measures

    Rick Dooley, PA-C
    Thomas Chittenden Health Center

    Alder Brook Family Health
    Essex Pediatrics
    Evergreen Family Health Lakeside Pediatrics 
    Richmond Family Medicine PLLC 
    Thomas Chittenden Health Center, PLC 

    Toby Sadkin, MD
    Primary Care Health Partners

    Cold Hollow Family Practice 
    Brattleboro Primary Care, 2 sites 
    Monarch Maples Pediatrics, 2 sites 
    Mt. Anthony Primary Care 
    St. Albans Primary Care 
    Timber Lane Pediatrics, 3 sites 

    Jeri Wohlberg, FNP 
    Northern Counties Health Care, Inc 

    Concord Health Center 
    Danville Health Center 
    Hardwick Health Center 
    Island Pond Health Center 
    Kingdom Internal Medicine 
    NVRH Corner Medicine 
    NVRH St. Johnsbury Pediatrics 
    St. Johnsbury Community Health Center

    Lance Broy, MD
    Lamoille Health Partners 

    Lamoille Health Family Medicine – Cambridge 
    Lamoille Health Family Medicine – Morrisville 
    Lamoille Health Family Medicine – Stowe 
    Lamoille Health Pediatrics 
    North Country 

    Kerry Goulette, PA-C 
    Community Health Centers Burlington 

    CHC Burlington (Riverside) 
    CHC Champlain Islands 
    CHC Essex 
    Good Health Center 
    South End Health Center 
    Winooski Family Health 

    Job Larson, MD
    Community Health Centers of Rutland Region

    Allen Pond Community Center
    Brandon Medical Center
    Castleton Family Health Center
    CHCRR Pediatrics
    Community Health North Main Street
    Drs. Peter and lisa Hogenkamp
    Mettowee Valley Family Health Center
    Rutland Community Health Center
    Shorewell Community Health Center 

    Aida Advic, MD
    Brattleboro Memorial Hospital

    Brattleboro Family Medicine
    Brattleboro Internal Medicine
    Maplewood Family Practice
    Putney Health Center
    Windham Family Practice 

    Keith Robinson, MD
    Jeremiah Eckhaus, MD
    Central Vermont Medical Center PHSO
    University of Vermont Health Network PHSO

    CVMC Adult Primary Care – Barre 
    CVMC Family Medicine – Berlin  
    CVMC Family Medicine – Mad River  
    CVMC Family Medicine – Main Campus 
    CVMC Adult Primary Care – Waterbury CVMC Green Mountain Family Medicine – Montpelier  
    CVMC Pediatrics Primary Care – Berlin PMC Primary Care – Brandon   
    PMC Primary Care – Middlebury     
    PMC Primary Care – Vergennes 
    UVM Children’s Hospital Pediatrics 
    UVMMC Adult Primary Care – Burlington 
    UVMMC Adult Primary Care – Essex 
    UVMMC Adult Primary Care – South Burlington 
    UVMMC Adult Primary Care – Williston 
    UVMMC Family Medicine – Colchester 
    UVMMC Family Medicine – Hinesburg 
    UVMMC Family Medicine – Milton
    UVMMC Family Medicine – South Burlington 

    Compliance

    Compliance Concerns?

    OneCare workforce and participating network members both have a duty to report any possible misconduct or violation of law. If you have an OneCare-related compliance or privacy question or concern, you should:

    • Report your concern to your organization’s compliance or privacy officer
    • Report the concern through the OneCare Compliance Hotline.

    OneCare Compliance Hotline:
    802-847-7220 or Toll-free 877-644-7176 (Select Option 2) 

    OneCare Compliance Hotline Email:
    OneCareVTHotline@OneCareVT.org 

    Or fill out our anonymous contact form. 

    Reports remain confidential and retaliation is prohibited. 

    Contact Us

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